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THIS IS TO CERTIFY:
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That the ship is exempted from the provisions of the Convention, under the authority by article
6(2)/6(4)* of the Convention referred to above.
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The provisions of the Convention from which the ship is exempted under article 6(2) are:
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______________________________________________________________________________________
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______________________________________________________________________________________
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______________________________________________________________________________________
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The voyage for which exemption is granted under article 6(4) is:
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From:_________________________________________________________________________________
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To:___________________________________________________________________________________
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Conditions, if any, on which the exemption is granted under either article 6(2) or article 6(4):
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______________________________________________________________________________________
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______________________________________________________________________________________
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______________________________________________________________________________________
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This Certificate is valid until the _________ day of _____________________________ subject to
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annual inspections in accordance with Article 14 (1) (c) of the Convention.
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Completion date of the survey on which certificate 1s based: …………………………..
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Issued at __________________ Date: The _________ day of ___________________________
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Seal
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DIRECTOR, MARITIME
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ADMINISTRATION - .................................... :__________________________
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(Signature of authorized
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official issuing the certificate)
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№ ………….
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______________________
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* Delete as appropriate
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ENDORSEMENT FOR ANNUAL SURVEYS
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THIS IS TO CERTIFY that, at an annual survey required by Article 14 (1) (c) of the Convention,
the ship was found to comply with the conditions under which this exemption was granted.
______________________________________________________________________________________
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Annual survey
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Place __________________________ Date __________________
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Seal MARITIME
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ADMINISTRATION: ________________________________
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(Signature of authorized official)
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___________________________________________________________________________________________________
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Annual survey
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Place __________________________ Date ___________________
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Seal MARITIME
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ADMINISTRATION: ________________________________
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(Signature of authorized official)
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___________________________________________________________________________________________________
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Annual survey
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Place __________________________ Date ___________________
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Seal MARITIME
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ADMINISTRATION: ________________________________
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(Signature of authorized official)
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___________________________________________________________________________________________________
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Annual survey
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Place __________________________ Date ___________________
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Seal MARITIME
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ADMINISTRATION: ________________________________
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(Signature of authorized official)
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Annual survey in accordance with article 19(8)(c)
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THIS IS TO CERTIFY THAT at a survey in accordance with Article 19(8) (c) of the Convention, the
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ship was found to comply with the relevant requirements of the Convention.
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Place __________________________ Date ___________________
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Seal MARITIME
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ADMINISTRATION: _______________________________
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(Signature of authorized official)
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Endorsement to extend the certificate if valid for less than 5 years where article 19 (3) applies
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The ship complies with the relevant requirements of the Convention, and this certificate shall, in accordance with article 19(3) of the Convention, be accepted as valid until:_______________________________________________
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Place __________________________ Date ___________________
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Seal MARITIME
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ADMINISTRATION: _______________________________
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(Signature of authorized official)
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Place __________________________ Date ___________________
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Endorsement where the renewal survey has been completed and article 19 (4) applies
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The ship complies with the relevant requirements of the Convention, and this certificate shall, in accordance with article 19(4) of the Convention, be accepted as valid until:_______________________________________________
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Place __________________________ Date ___________________
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Seal MARITIME
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ADMINISTRATION: _______________________________
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(Signature of authorized official)
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Endorsement to extend the validity of the certificate until reaching the port of survey or for a period of grace where article 19(5) or 19(6) applies
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This certificate shall, in accordance with article 19(5)/19(6)* of the Convention, be accepted as valid until ________________________________________________________________________________
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Place __________________________ Date ___________________
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Seal MARITIME
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ADMINISTRATION: _______________________________
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(Signature of authorized official)
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Endorsement for advancement of anniversary date where article 19(8) applies
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In accordance with article 19(8) of the Convention, the new anniversary date is: __________________________
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Place __________________________ Date ___________________
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Seal MARITIME
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ADMINISTRATION: _______________________________
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(Signature of authorized official)
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In accordance with article 19(8) of the Convention, the new anniversary date
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is: __________________________
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Place __________________________ Date ___________________
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Seal MARITIME
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ADMINISTRATION: _______________________________
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(Signature of authorized official)
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* Delete as appropriate.
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